Katie Madden’s mother speaks out after coroner’s answers

It has been more than three months since the investigation into the death of tragic Katie Madden was concluded.

The Lowestoft mother who died by suicide after a Clare’s Law disclosure was revealed suffered a series of devastating blows.

But one thing was a constant – the love she felt for her children, even in her darkest days.

Senior Coroner Nigel Parsley (Image: Newsquest) Senior coroner Nigel Parsley conducted an emotional inquest into the 32-year-old’s death earlier this year.

The evidence he heard led him to release a Prevention of Future Deaths (PFD) report after hearing how Katie struggled to get help for her deteriorating mental health.

After the trial, Katie’s mother Bernadette Sutton described how her daughter’s life had fallen apart.

She has now expressed her determination to ensure Katie’s death was not in vain.

Suffolk Coroner’s Court (Image: Newsquest)

What the coroner said

Mr Parsley condemned the services involved in Katie’s case.

He passed the PFD report on to Norfolk and Suffolk NHS Foundation Trust (NSFT), Suffolk County Council and Suffolk Police.

It was also issued to the Department of Health and Social Care, the Minister for Victims and Protection and the Norfolk and Waveney Integrated Care Board (ICB).

The report raised concerns about a lack of support for Katie after she received information under the Domestic Violence Disclosure Scheme, also known as Clare’s Law.

This police policy gives people the right to find out whether their partner or ex-partner has experienced abuse or violence in the past.

It was introduced ten years ago following a campaign by the father of 36-year-old Clare Wood, who was strangled and set on fire in Salford in 2009 by an abusive ex-boyfriend.

Mr Parsley’s report said: “There was no formal system in place to provide additional support to Kate herself, even though she was known to be at risk.”

It goes on to say that any impact on her mental health or physical wellbeing was “not taken into account”.

The inquest was told mental health professionals had assumed she had her own social worker and expressed surprise when they found this was not the case.

Katie Madden (Image: Provided by the family)

THE ANSWERS

The coroner’s court has received responses from those to whom the PDF report was addressed.

Suffolk County Council agreed that there is currently no statutory or other national system in place to address the needs of vulnerable parents who are faced with caring for their child or children.

It said it would “welcome any interventions that relevant foreign ministers can offer in relation to working with partnerships”.

The council said measures are already underway to ensure vulnerable parents are referred to adult social care by the children and young people team.

This follows a Serious Case Review into the death of another Suffolk mother, known as Mandy, who died of an overdose leaving behind six children.

The NSFT went on to say that following Katie’s death, it would ask all doctors to identify where treatments were recommended by non-NSFT clinics.

This is to allow further assessment in the event that NSFT can offer alternative treatment or further guidance.

The ICB confirmed that it had “not lost sight of the suffering caused by Ms Madden’s death”, but only confirmed what was already known, namely that no application for funding had been made.

In its response, Suffolk Police said it carries out its own risk assessment when making Clare’s Law disclosures to take into account the welfare of the recipient.

It added: “We have reviewed police files and can confirm that at the time of the Clare’s Law disclosure (…) this was done in line with policy and appropriate follow-up.”

“There is no evidence in the police files that there were any concerns about Katie’s mental health at the time of the disclosure decision or that any previous police incidents had been recorded.”

Baroness Merron, parliamentary secretary of state for patient safety, women’s health and mental health, said the circumstances described in the report were “deeply worrying”.

HAVE LESSONS LEARNED?

Since her daughter’s death, Ms. Sutton says not a day goes by when she doesn’t think about what could have been done differently.

As an NHS worker, she says the report came too late to make a difference and that the responses to the coroner were “inadequate”.

“I keep looking at the report and the responses,” she said. “One minute I understand it, and the next I don’t understand it anymore.

“I worry all the time and it’s on my mind.

“Much more could have been done, but it won’t bring them back. It is too late. It is now too late for us as a family and the children.

“I get so angry sometimes. I just feel like I can’t blame anyone for how he treated her.

“No one saw her as an individual, she was a nobody in their eyes, but she screamed for help.”

Katie Madden and her mother Bernadette Sutton (right) (Image: Provided by the family)She added that there needed to be more “common sense and personal responsibility” in support services.

“There is still no joint collaboration,” she said.

“All services have problems, I understand that, but mental health has been at the bottom of the list for many, many years. It’s just a hamster wheel.

“Many of these laws, like the Clare Act, are enacted and then forgotten and buried.

“Katie’s death was also a slap in the face to Clare’s family.”

Ms Sutton is determined to ensure that no parent suffers as Katie did and has offered to speak to the various organizations and experts involved in Katie’s care to tell her story.

“It doesn’t matter if it takes me two years, three years or whatever, I’m not done with it, I’ll never be done with it.

“Hopefully something will be done in Katie’s name. Where would she want me to start? She would probably want me to help others because she was such a kind and caring person.”

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